1
Q
Acne
What is acne?
A
Acne vulgaris is a multifactorial inflammatory disease with blockage and/or inflammation of the pilosebaceous gland of the skin.
2
Q
Acne
Types of lesions
A
- comedones: whiteheads/blackheads are build up of sebum, bacteria, and dead skin cells in the pilosebaceous gland.
- papules: red raised bumps (w/out pus)
- pustules: papules containing pus
- cyst: deep pustule
- nodule: tender, red, swollen lesions with undefined borders
listed from least severe to most.
Clogged Pores Produce Nasty Cysts (Comodones, Papules, Pustules, Nodules, Cysts)
3
Q
Acne
Patho of acne
A
excessive sebum production triggered by internal and external factors, follicular hyperkeratinization, proliferation of the anaerobic microorganism (Cutibacterium acnes). Leads to inflammatory mechanisms.
Other causes: hormones, diet, stress, and genetics all contribute.
4
Q
Acne
Different between whiteheads and blackheads?
A
Whiteheads are blockages that are deeper (closed comedone), blackheads are closer to the surface and therefore get oxidized (open comodone).
5
Q
Acne
Clinical presentation of acne
A
Comedonal acne - open or closed comedones
inflammatory acne - papules, pustules, nodules, or cysts
Classification based on number, type and distribution of lesions.
6
Q
Acne
Severity classication of acne
A
Mild: comodones, few papules and pustules. NO nodules, cysts, or scarring.
Moderate: several papules and pustules. Few nodules. NO cysts, mild scarring.
Severe: numerous papules, pustules, nodules, and cysts. Moderate to severe scarring.
7
Q
Acne
Risk factors for acne
A
- diet (controversial)
- hormones
- mechanical/physical factors
- stress
- topical agents
- drugs (steroids, phenytoin, lithium, androgens, progestin-onlu contraceptives)
8
Q
Acne
Diagnosis of acne
A
based on clinical presentation. C+S of pustules ONLY if concern for gram-negative folliculitis.
* hormonal investigations if signs of hyperandrogenism (hirsutism, infertility, irregular periods, insulin resistance, onset in middle aged women)
* medication induced if on ASMs, TB drugs, lithium, cobalt in vit B12, corticosteroids.
9
Q
Acne
When to refer for acne
A
- Present at young age (pre-puberty) or > 30
- widespread distribution of lesions (comedones > 20, inflammatory lesions > 15, total lesions > 30)
- mod to severe acne (presense of nodules, cysts, or scarring)
- drug or condition-induced acne
- non-responsive or worsening sxs after 2-3 m of tx
- possible hyperandrogenism or other endocrine abnormality
- excessive embarrassment, anxiety, depression, low self-esteem, or feelings of shame
10
Q
Acne
Non-pharm for acne
A
- do not pick/squeeze
- use gentle skin cleaning techniques
- avoid occluding products
- eat low glycemic diet and minimize stress (both controversial)
- chemical peels, microdermabrasion, and photodynamic therapy have little evidence supporting efficacy.
11
Q
Acne
Mild acne treatment algorithm
A
BPO or topical retinoids
OR both
OR BPO/clindamycin
OR BPO/adapalene
If no improvement after 2-3 months - combined oral contraceptive (for female)
12
Q
Acne
Moderate acne treatment algorithm
A
BPO
or topical retinoids
or combo of both
or BPO/clindamycin
or BPO/adapalene
plus
COC or systemic abx (tetracyclines)
if no improvement in 2-3 months - refer to dermatologist.
COC = combined oral contraceptives
13
Q
Acne
Severe acne treatment algorithm
A
Oral isotrentinoin
if no improvement after 2-3m - refer to dermatologist
if pt unwilling, unable, or intolerant - systemic abx w/ topical BPO +/- topical retinoid OR COC (if no improvement in 2-3m - refer).
14
Q
Acne
Types of topical vehicles based on skin type
A
- oily skin = solutions/gels
- dry/sensitive skin = creams
- any skin type = lotions
15
Q
Acne
Which ingredients are exfoliants
A
Glycilic acid, salicylic acid, sulfur (OTC)
16
Q
Acne
What ingredients are antimicrobials w/ anti-inflammatory properties?
A
Benzyl peroxide, dapasone
17
Q
Acne
Which ingredients are antimicrobials with keratolytic properties?
A
Azelaic acid
18
Q
Acne
Which ingredients are retinoids?
A
adapalene, tazarotene, tretinoin, trifarotene
19
Q
Acne
which ingredients are abx?
A
clindamycin, erythromycin
20
Q
Acne
Oral agents for acne?
A
- abx: tetracycline, doxycycline, minocycline, trimethoprim-sulfamethoxazole, azithromycin.
- hormonal therapy: COCs, spironolactone
- retinoids: isotrentinoin
21
Q
Acne
OTC/non-Rx acne options?
A
- BPO - no rx req. for concentrations < 5.1%
- glycolic acid
- salicylic acid - less effective then BPO
- sulfur - often combined w/ salycylic acid
22
Q
Acne
BPO information
A
Apply once daily, gradually increase to 2-3 times/day prn. may take up to 3m to see improvement (initial worsening in first 2-4 weeks).
Can prevent/eliminate C. acnes.
2.5% similary efficacy to 5% and 10%.
Gel formulation improves absorption.
Degrades topical retinoids - must seperate (BPO in AM, retinoid in PM)
Can bleach clothing and hair.
AEs: bleaching, skin irritation, peeling.
23
Q
Acne
Salicylic acid information
A
1-2% strength, higher concentrations are more irritating. Not as effective as topical retinoids.
24
Q
Acne
Glycolic acid information
A
2-15% strength
used when topical retinoids are not tolerated.
25
# Acne
Azelaic acid information
Apply BID. Some effect at reducing inflammation but not as much as BPO. Most effective in combo w/ other agents. Can cause hyper or hypo pigmentation.
26
# Acne
Dapason information
Apply BID. best used in inflammatory acne. Mildly irritating and available in a topical gel formulation.
Not used orally due to serious AEs.
27
# Acne
Clindamycin/erythromycin information
Apply once or twice a day (depends on formulation)
slow acting, for papulopustular acne to decrease C. acnes
resistence often develops over time with monotherapy - use with BPO to decrease risk.
May take 8-12 weeks to see improvement.
28
# Acne
Topical retinoids information
Apply at bedtime and seperate from BPO.
Efficacy may take months. Initial worsening.
Tretinoin (most cost effective, most photosensitizing), adapalene (least irritating), tazarotene (most potent)
Micronized tretinoin improves delivery of retinoid and reduces irritation.
AEs: skin dryness, redness, skin peeling. Use a good moisturizer. Skin more sensitive to light and drug degrades with sun exposure - USE SUNSCREEN. CI in pregnancy!!!
29
# Acne
Systemic abx information
Tetracyclines considered 1st line (doxy, tetra > mino bc more AEs with mino (drug-induced lupus, hepatitis, cutaneous pigmentation, dizziness, vertigo).
Consider in mod-severe acne or if topical therapy is ineffective after 2-3m.
Trial 6 weeks of therapy for effectiveness, limit duration to 3m, use with topicals.
Combine w/ BPO to decrease resistance - DO NOT USE AS MONOTX.
Reserve other abx (macrolides, SMX-TMP) for last line.
AEs: GI upset, yeast overgrowth, photosensitivity, pseudotumor cerebri. CI in pregnancy and in children < 8.
30
# Acne
Oral retinoids information
Most powerful anti-acne agent, decrease sebum production and inflammation. Useful for severe nodulocystic and non-responsive acne. Most effective tx w/ remission lasting beyond duration of therapy.
Teratogenic - CI in pregnancy and breastfeeding
Women of childbearing age: complete baseline + monthly pregnancy tests + 2 reliable methods of contraception until 1m after last dose. Wait 8 weeks after therapy completion before pursuing additional courses.
CI w/ tetracyclines (risk of pseudotumor cerebri) - 7 day washout.
31
# Acne
Oral retinoids AEs
* Common: drying/chapping of skin (moisturize), h/a, myalgias, arthralgias, photosensitivity (use sunscreen), mild nosebleed.
* uncommon/rare AEs: lipid abnormalities (hypertriglyceridemia), pseudotumor cerebri, mood disorders, erythema multiforme, SJS/TENS
32
# Acne
Hormonal contraceptives information
If acne worsens with menstrual cycles consider COCs.
COCs with minimal androgenic effects (4th gen progest) or with antiandrogenic effects (cyproterone acetate or drospirenone (increase VTE risk).
D/c 3-4 cycles after acne has been resolved.
AEs: breakthrough bleeding, n/v, weight gain, bloating, breast tenderness, depression, h/a, chloasma.
Rare AEs: thromboembolism, stroke, MI, retinal artery thrombosis, benign liver tumour, gallstone formuation, htn.
DIs: rifampin decreases estrogen levels.
33
# Acne
Spironolatone information
form of antiandrogenic hormonal therapy used in selected women.
Effective contraception recommended in women of child-bearing age.
AEs: hyperkalemia, diuresis, irregular menses, breast tenderness, n, h/a, fatigue, dizziness.
34
# Acne
Acne tx options in pregnancy
* BPO, erythromycin (systemic or topical), topical clindamycin, glycolic acid, azelaic acid, intralesional corticosteroids (triamcinolone)
* **NOT RECOMMENDED: isotretinoin (systemic), retinoids (systemic or topical), erythromycin (estolate salt), SMX-TMP, spironolactone, tetracycline, doxycycline, minocycline (esp. in 2/3rd trimester), oral contraceptives**
35
# Acne
Acne tx options if breastfeeding
* topical abx, BPO, topical retinoids, azelaic acid, glycolic acid, spironolactone, erythromycin (increased risk of pyloric stenosis), tetracycline (< 3 weeks)
* **NOT RECOMMENDED: retinoids (systemic), isotretinoin (systemic), SMX-TMP, tetracycline, doxycycline, minocycline**
36
# Acne
Patient counselling points
* wash face gently w/ water and mild soap
* avoid abrasive cleansers, vigorous scrubbing, and astringents
* apply a sunscreen daily and avoid excessive sun exposure
* use non-comedogenic moisurizer to reduce irritation
* apply thin later of cream
37
# Acne
Monitoring for acne
* assess efficacy of tx at 2-3m if no response or sxs worsening after 2-3m, refer
* if inadequate response - consider swtiching topical agents, combining agents, or adding a topical abx (for inflammatory sxs)
* if responds well to tx, may contact primary care provider for refills (BPO and topical retinoids can be used for maintenance).
* Assess for AEs + recommend management: skin dryness (fragrence-free, water based moisturizing cream), excessive skin irritation w/ BPO/retinoids: decrease strength and frequency.
38
# Acne
Therapeutic tips for acne
* topical therapy should be used as frequently as prescribed to the affected zones and not to the lesions alone.
* topical BPO/abx formulations have short shelf-lives
* allow for several weeks of tx to assess effectiveness
* cream is better for pts w/ dry/sensitive skin while gels are best for oily skin and those who live in hot/humid climates.
* gradually taper up tretinoin to avoid local irritation and increase tolerability (e.g. less frequent applications, shorter contact times)
* disease can last years, once control is acheived regimen can be simplified
* When used to gether apply BPO in AM and retinoid in PM.
* use topical abx w/ BPO.
* 7 day washout b/w tetracycline and isotrentioin.
39
# Pruritis
What is pruritis?
Itchy skin that may stem from an underlying cause or condition.
Acute if < 6 weeks, chronic if > 6 weeks.
Some causes: pregnancy, allergic reactions, dry skin (xerosis), nervous system disorders, skin conditions, drugs, systemic diseases, etc.
40
# Pruritis
Clinical presentation and risk factors of pruritis?
Presentation: Itching, redness, dryness, cracked skin, bumps, blisters, lethery/scaly texture.
Risk factors: chronic renal disease, chronic liver disease, atopy, seasonal/environmental allergies.
41
# Pruritis
Diagnosis of pruritis?
## Footnote
FYI
* pt hx: location, duration, and severity of sxs; aggravating and releiving factors; hx of systemic diseases; skin care and cleansing routine; fever, chills, and night sweats; unintended weight loss; prescription/non-prescription meds, NHPs, and illicit drug use; change in products that touch skin (soap, laundry detergent, etc.)
* physical exam: skin rash, burrows, excoriations, dermatographism, abnormal skin pigmentation, lymphadenopathy, hepatosplenomegaly.
* lab investigations: required if a primary dermatological cause has been ruled out. CBC w/ differential, fasting serum glucose levels, renal function tests, LFTs, thyroid function tests, chest x-ray, HIV tests.
42
# Pruritis
Drug causes of pruritis
Abx (penicillins, TMP-SMX, quinolones), heparin, ACEi, CCBs, BBs, Hydrochlorothiazide, statins, opioids, chloroquine, hydroxyethyl starch used in IV therapy (12-54% of patients), EGFR inhibitors (cancer - e.g. gefitinib), granulocyte colony stimulating factor (G-CSF), interleukin-2.
43
# Pruritis
Non-pharm options for pruritis
* avoid aggravating factors
* break the itch-scratch cycle (cool compress, colloidal oatmeal/baking soda bath, trim fingernails)
* minimize friction and skin irritation
* skin hydration (may keep cream in fridge to offer additional releif)
* ensure adequate sleep
* behavioral therapy, relaxation, stress reduction
44
# Pruritis
topical pharm tx for pruritis
* menthol or camphor
* zinc oxide (10-50%)
* pramoxine 1%
* calamine
* costicosteroids
* tacrolimus and pimecrolimus
* capsaicin - if along nerve lines.
45
# Prurits
Systemic pharm tx for pruritis
* antihistamines (2nd gen preferred, 1st beneficial for sleep) - urticaria only
* doxepin - various including: chronic urticaria, psychogenic
* mirtazapine - various
* paroxetine, sertraline, and fluvoxamine - CKD, malignancies, cholestasis
* gabapentin and pregabalin - uremic, neuropathic
* naltrexone and butorphanol - opioid induced
* difelikefalin - CKD, hemodialysis
~FYI~
* ketotifen - uriticaria and mastocytosis
* montelukast - adjuvant to antihistamines for severe urticaria, uremic
* cholestyramine and colestipol - cholestatic liver disease
* rifampin - chronic cholestasis
* serotin antagonists (ondansetron) - hepatic/renal (limited effectiveness)
* aprepitant - cancers and biological cancer tx
* systemic steroids - cutaneous inflammation and other therapies inappropriate
46
# Pruritis
Antihistamines information
* Drugs e.g., diphenhydramine
* AEs: dizziness, drowsiness, fatigue, rash, dry mouth, blurred vision. paradoxical excitation in children.
* use: only for urticaria, histamine is not involved in sxs of itching. Sometimes used for sedative effects (1st gen)
47
# Pruritis
Astringents information
* drugs: calamine lotion
* AEs: skin irritation, skin drying if used long term
* use: on moist lesions, otherwise too drying
48
# Pruritis
Bath emollients information
* drugs: Colloidal oatmeal
* AEs: none
* use: add to warm (not hot) bath prn, soak 10-15 mins min.
49
# pruritis
counterirritants information
* drugs: menthol, camphor
* AEs: skin irritation at higher concentrations (both), excessive use can lead to systemic absorption leading to n/v/ h/a, dizziness, tremors, seizures (camphor > menthol)
* use: PRN to TID, elicits a cooling sensation, do not apply to large skin areas or open wounds. Avoid camphor in kids.
50
# pruritis
Local anesthetics information
* drug: pramoxine
* AEs: contact dermatitis, burning, stinging
* use: may consider. Do not apply to large areas of the skin or opwn wounds.
51
# pruritis
topical CS information
## Footnote
CS = corticosteroid
* drug: hydrocortisone 0.5-1% cream
* AEs: local irritation, burning, dryness
* use: indicated only for pruritis due to cutaneous inflammation, do not use long term, chronic pruritis and use not recommended on face, groin, axillae, or open skin lesions.
52
# pruritis
pruritis alorithm/considerations
generalized pruritis → skin rash? (if yes tx underlying cause) if no → assess for systemic disease (if yes tx underlying cause) if no → drug-induced? (if yes d/c suspected drug for 6 weeks min.) if no → treat sxs. if no improvement consider psychogenic causes.
53
# pruritis
monitoring pruritis efficacy and safety
**Efficacy**
* pruritis, redness, dryness improved in days-weeks
* secondary infections prevented, ongoing.
**Safety**
* local skin reactions are minimized, ongoing.
* AEs of systemic therapy is mimimized, ongoing.
54
# Lice
Louse life cycle
Females lay ~ 7-10 eggs (nits)/day - attach firmly to hair shaft.
Nits hatch in 8-10 days releasing nymphs.
Nymphs mature into adults in 8-15 days.
life span of lice is about 30 days on the head.
Lice can life 1-2 days without a host.
55
# Lice
Clinical presentation of lice
May be asymptomatic - often pruritis, visualization of lice/nits, papules.
intense scratching may cause a recondary infection, which results in pustules, cellulitis, fever, enlarged nuchal and cervical lymph nodes.
56
# Lice
Non-pharm therapy for lice
* examine close human contacts for infection
* avoid sharing belongings and direct close contact
* physically remove nits
* disinfect combs and brushing with Lysol 2% (1 hour), rubbing alcohol (10-20 mins), or hot water (5-10 mins).
* wash all exposed bedding, towels, personal articles, + clothing in hot cycle.
* For items that can't be washed, seal in plastic x 2 weeks.
* vacuum areas that came into contact w/ the infected person(s)
57
# Lice
Pharm therapy for lice
* Permethrin 1% (Nix, Kwellada-P) - 1st line
* pyrethrins/piperonyl butoxide (R&C shampoo) - 1st line
* isopropyl myristate/cyclomethicone (Resultz 50%/50%) - 2nd line
* dimethicone 50% (NYDA) - 2nd line
58
# Lice
Permethrin 1% information
* 1st line.
* MOA: neurotoxic insecticide.
* AEs: local irritation
* Special considerations: CI in children < 2m, compatile in P/L.
* comments: tx failure may be due to resistance; repeat tx in 7 days.
59
# Lice
Pyrethrins/piperonyl butoxide information
* 1st line
* MOA: neurotoxic insecticide.
* AEs: local irritation
* Special considerations: CI in < 2 y/o, compatible in P/L.
* Comments: tx failure may be due to resistance, repeat tx in 7 days.
60
# Lice
Isopropyl myristate/cyclomethicone information
* 2nd line
* MOA: disrupts wax layer of louse exoskeleton, physically kills via dehydration.
* AEs: local irritation
* Special considerations: not rec. in < 4 y/o or P/L.
* Comments: unlikely to develop resistance; repeat tx in 7 days.
61
# Lice
Dimethicone information
* 2nd line
* MOA: silicone based oils that coat louse and physically kills via suffocation.
* AEs: local irritation
* Special considerations: not rec. in < 2 or P/L.
* Comments: unlikely to develop resistance, repeat tx in 8-10 days.
62
# Lice
Pyrethrin considerations re: allergies?
Possible cross sensitivity in pts with ragweed allergies due to cross sensitivity. CI in pts with chrysanthemum allergy (on monograph).
Likely safe in chrysathemum/ragweed allergy via Canadian Pediatric Society.
63
# Lice
How to apply permethrin?
* shampoo hair (no conditioner) and towel dry
* apply tx to haur and scalp, ensure thoroughly soaked (1/2 bottle - 1 bottle for adults/children w/ long hair)
* leave tx on for 10 mins then rinse
* comb out and remove lice and nits
* may repeat tx in 1 week if live lice are observes (recommended b/c not 100% ovicidal)
64
# Lice
How to apply pyrethrins/piperonyl butoxine?
* apply treatment to dry hair and scalp
* massage until hair is completely saturated
* leave tx on for 10 mins then add water
* lather then rinse over sink
* comb out lice/nits
* repeat tx in 7 days
65
# Lice
how to apply isopropyl myristate/cyclomethicone?
* apply tx to dry hair/scalp
* massage until hair is completely saturated
* leave tx on for 10 mins
* rinse out
* comb out lice/nits
* repeat tx in 7 days
66
# Lice
How to apply dimethicone?
* spray onto dry hair/scalp
* massage until hair is completely saturated
* leave on for 30 mins
* comb out lice and nits
* leave soluton to dry on hair for at least 8 hours
* wash hair
* repeat in 8-10 days
67
# Lice
Tx failure options for lice?
* switch to a different pharmacological class
* permethrin 5% cream applied to scalp + left overnight
* oral TMP/SMX w/ permethrin 1% applied to scalp and left on for 24H (adults)
* oral ivermectin 200 mcg/kg repeated in 7-10 days or 400 mcg/kg repeated in 7 days.
* *Itching alone is not a sign of tx failure!!!*
* No substantial evidence for: hot air, hair styling gels, mayonaise, vinegar, isopropyl alcohol, olive oil, butter, petroleum jelly, acetomicellar complex, or tea tree oil.
68
# Lice
Efficacy monitoring endpoints for lice
* eradicate live lice and presence of nits in 7-10 days
* no pruritis in 4-6 weeks
* prevent secondary infection, ongoing
69
# Scabies
Scabies life cycle
Scabies are a parasitic skin infection caused by mites called *Sarcoptes scabiei* variation *hominis*.
After fertilization, females burrow into skin and lay 2-3 eggs/d for entire 4-6 week lifespan.
in 3-4 days larvae hatch and head to skin surface to find mate.
Mature into adults in 14-17 days
process repeats
can survive away from host for 2-36 hours and room temperature and up to 19 days in cool, humid environments.
hypersensitivity (type IV) to mites, eggs, and feces causes intense pruritis that worsens at night.
70
# Scabies
Clinical presentation of scabies?
Intense pruritis that worsens at night, burrows on hands and flexor surfaces (white/gray linear or wavy lines beneath the surface of the skin), papules, secondary infections, crusted scabies in immunocompromised hosts are more contagious w/ high secondary infection rate, atypical presentation in children on hands, feet, scalp, and body folds.
pts may be asymptomatic for up to 6 weeks after infestation (due to delayed hypersentitivity rxn), no delay in re-infestation.
Distribution: webs of fingers, wrists, axilla, knees, male genitalia and skin under breasts, skin folds around belt line, navel, buttocks, thighs.
71
# Scabies
Non-pharm therapy for scabies
* avoid sharing belongings and direct physical contact
* wash linenes and clothes in hot cycle
* seal items that cant be washed (at least 3-7 days)
* vacuum areas that came in contact w/ infected person(s)
* children can return to school day after tx is completed
* trim fingernails to avoid injury from excessive scratching
72
# Scabies
Pharm tx for scabies
* 1st line: permethrin 5% applied to all skin areas, left on for 8-14 hours, then wash off.
* 2nd line: sulfur 5-10% applies to all skin areas at bedtime for 3 consecutive days, leave on for 24 hours, wash off prior to next application
73
# Scabies
Applying topical tx for scabies
* apply to clean, dry skin
* massage thin layer into all skin areas from the neck down to the toes (including fingernails, waist, genitalia)
* leave on for x hours then wash off
* may repeat tx in 1 week if mites are still active
* pruritis may persist for 1-2 weeks after successful tx
74
# Scabies
efficacy monitoring endpoints for scabies tx
* eradicate burrows and papules in 7-14 days
* eradicate pruritis in 4 weeks
* prevent secondary infection, ongoing
75
Pharm
flashcards
Decks in class (65)
# Cards
-
CV118
-
Oncology336
-
Obesity69
-
HIV145
-
Hypertension32
-
Infectious Diseases269
-
Endocrine118
-
Major Depressive Disorder AND Anxiety42
-
CYP Substrates, Inducers, and Inhibitors3
-
Fluid + Lytes Balance0
-
PK for Adults0
-
PK for Children0
-
PK for Special Populations0
-
Respiratory19
-
Ischemic Heart Disease0
-
Physiology and Anatomy0
-
Insomnia0
-
Schizophrenia0
-
Bipolar Disorder0
-
Eating Disorders0
-
Substance Use Disorders0
-
ADHD0
-
Seizures0
-
Parkinson's0
-
Liver0
-
Kidney0
-
Glaucoma0
-
Pregnancy and Lactation0
-
Cystic Fibrosis0
-
Women's Health0
-
Men's Health0
-
Gender Affirming Care0
-
Transplants0
-
Immunizations0
-
Smoking Cessation0
-
Pain12
-
Stroke0
-
Anemia0
-
Contraception0
-
VTE0
-
Steroids (Cushing's and Addison's)0
-
Sexually Transmitted Infections0
-
Osteoporosis0
-
OTC's23
-
Osteoarthritis and Rheumatoid Arthritis0
-
Multiple Sclerosis0
-
Migraines and Headaches0
-
Arrhythmias1
-
Pharmacy Law0
-
Medicinal Chemistry0
-
Ethics0
-
Pharmaceutics0
-
Pharmacokinetics0
-
Toxicology0
-
Healthcare System + Ethics/Law4
-
Things a girl ought to know16
-
Oncology Last Minute Reminders41
-
PE/VTE19
-
Labs3
-
GI and GU48
-
Drugs34
-
Hospital practice stuff23
-
Derm75
-
Patient Care Process9
